Vincenzo Speranza

Magnetic resonance-cholangiopancreatography in the diagnosis of biliopancreatic diseases

BACKGROUND Magnetic resonance cholangiopancreatography (MRCP) is a new, noninvasive imaging technique for the visualization of the biliary ducts with cholangiographic images similar to those obtained with endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. No contrast medium injection is used. The aim of this study was to assess the feasibility of MRCP versus ERCP in the diagnosis of biliary tract and pancreatic diseases. PATIENTS AND METHODS One hundred and thirty-six patients were submitted to MRCP. They were referred to MR study according to four inclusion criteria: (1) evidence or suspicion of choledocholithiasis, (2) benign or malignant bile ducts stenosis, (3) follow-up of patients submitted to biliary-enteric anastomosis, and (4) chronic pancreatitis with Wirsung duct dilatation. The MRCP was performed with a 0.5T superconducting magnet (Philips Gyroscan T5). When neoplastic disease was detected, additional images on axial planes were acquired. MRCP allowed images of diagnostic value to be obtained in all the cases. RESULTS In choledocholithiasis, MRCP showed 91.6% sensitivity, 100% specificity, and overall diagnostic accuracy 96.8%. Of 48 patients with stenotic lesions, 16 were correctly characterized as benign and 30 as malignant. Two cases of focal chronic pancreatitis were misdiagnosed as pancreatic head carcinoma. In the patients submitted to biliary-enteric anastomosis, MCRP was able to detect the dilatation of the intrahepatic ducts, the stenosis, and associated stones in all 8 positive cases. In the remaining 7 patients with mild signs of cholangitis, MCRP showed irregular aspects of the biliary tree in the main ducts. In the 11 patients with chronic pancreatitis, MCRP was able to depict the dilated Wirsung duct and the stenotic tract, although the fine details of the secondary ducts were not evaluated due to the low spatial resolution as compared with conventional films. CONCLUSIONS MRCP can be considered a technique able to completely replace diagnostic ERCP. Further studies are necessary for a better evaluation of the potential advantages and disadvantages of this technique.

CIMETIDINE AND ANTACID PROPHYLAXIS OF ACUTE UPPER GASTROINTESTINAL BLEEDING IN HIGH - RISK PATIENTS

A randomized, controlled clinical trial was performed to compare the efficacy of prophylactic cimetidine treatment, antacid treatment and no treatment in high risk patients. Sixty patients received cimetidine (200 mg every 6 hours), 52 patients received antacids (Maalox, 10 ml/hour), and 56 patients received no treatment. One hundred thirty-five patients completed the study. Eight patients in the control group and one patient in the antacid-treated group presented with upper gastrointestinal bleeding. No bleeding occurred in the cimetidine-treated group. Patients considered at low risk had no bleeding. Cimetidine or antacid prophylaxis significantly decreased the incidence of upper gastrointestinal bleeding in the high risk patients.

Intrahepatic lithiasis: Study of thirty-six cases and review of the literature

In 2,700 operations for biliary tract stones, intrahepatic lithiasis (stones located proximal to the confluence of the main hepatic ducts) was discovered in 36 patients (1.3 per cent). The diagnosis of intrahepatic lithiasis was determined only via intraoperative chalangiography in thirty-two cases (88.9 er cent); in 23 per cent of our cases of intrahepatic lithiasis, jaundice was never observed. This confirms that intraoperative cholangiography should be performed routinely in every case of biliary lithiasis. The removal of stones was generally performed by an indirect approach (papillostomy and/or choledochotomy). In 16.7 per cent of our cases, a direct approach was indicated. It is extremely important, after removal of calculi, to assure ample bilioenteric flow. Our surgical approach was therefore based mostly on the caliber of the biliary tract. When the tract was dilated less that 2 cm (in 20 cases), choledochohepaticotomy with papillostomy was most often performed (12 cases, 60 per cent). When the dilatation was more that 2 cm (12 cases), Roux-en-Y hepaticojejunostomy was performed in all. There was no operative mortality, although the long-term follow-up results were poor in 9.6 per cent of the cases.

Effector Th-1 cells with cytotoxic function in the intestinal lamina propria of patients with Crohn's disease

A large body of evidence points to a pivotal relationship between Th-1 cells and mucosal inflammation in Crohns disease (CD). The aim of the present study was to assess whether CD is associated with specific functional activity of lamina propria T lymphocytes (LPT), particularly purified CD4, such as cytotoxic activity and specific cytokine-secreted profile. The results showed that CD4 LPT in patients displayed a chronically activated memory-like surface phenotype and, when compared to controls, had a significantly enhanced antibody-redirected cytotoxicity. Interestingly, the ratio of perforin expression in CD4 LPT was higher compared to controls, and a redirected lysis of human RBC mediated by a CD4 subset of intestinal lamina propria was evident, suggesting a cytolytic pore-forming mechanism. Moreover, a unique Th-1 cytokine profile pattern in the CD4 cells from CD was defined. These effector cells produced 12 times more IFN-γ, two times more TNF-α, and three times less IL-4 than controls. In contrast, no increase in IL-2 was detected, while IL-5 was undetectable. Our studies suggest that these preexisting in vivo activated CD4 LPT may play an important role in the inflammatory process in CD, thus directly contributing to the intestinal lesions.

Acid and gastrin levels after bombesin and calcium infusion in patients with incomplete antrectomy.

In 17 patients with postoperative recurrent peptic ulcer, incomplete antrectomy (I.A.) was found by endoscopic biopsies in 5. No evidence of I.A. was found in the remaining 12 patients. Gastric acid output and gastrin levels were measured in basal conditions and following a calcium I.V. infusion (4 mg/kg hr of Ca++ over 4 hr) and a bombesin (BBS) I.V. infusion (15 ng/kg min over 90 min). Basal gastrin levels were significantly different in the two groups of patients: BBS infusion augmented significantly serum gastrin levels in all patients with I.A., while BBS infusion had no significant effect on serum gastrin levels in the group of patients wihtout I.A. Acid output following BBS infusion showed a pattern similar to the pattern seen for gastrin. Calcium infusion augmented gastric acid secretion and gastrin levels in the patients with I.A.; however, the response to calcium could not clearly separate in all instances patients with I.A. from patients without I.A. It is concluded that the “BBS infusion test” may be helpful in the diagnosis of I.A. in patients with postoperative peptic ulcer.

Effect of bombesin on extragastric gastrin in man.

The effect of a protein test meal and a bombesin infusion on extragastric gastrin levels was studied in patients with truncal vagotomy, antrectomy, and gastroduodenostomy or gastrojejunostomy and in patients with total gastrectomy. In patients with vagotomy, antrectomy, and gastroduodenostomy and in patients with total gastrectomy the gastrin levels were raised by 33% and 35%, respectively, from basal after test meal, while during BBS infusion gastrin values decreased by 25% and 30%, respectively, from basal. In patients with vagotomy, antrectomy, and gastrojejunostomy, test meal and BBS infusion did not significantly alter basal gastrin values. It is concluded that BBS does not stimulate extragastric gastrin.

Effect of caerulein in patients with biliary colic pain

A randomized placebo-controlled double-blind trial was carried out in 24 patients with biliary colic pain in order to evaluate the analgesic effect of caerulein (CRL). Caerulein (1 ng/kg . min infused intravenously over 15 min) showed an analgesic effect that was significantly higher than placebo (p less than 0.001). The analgesic action of CRL was not inhibited by naloxone (0.4 mg intravenously, administered two times). Further, the effect of i.v. CRL or saline on artificially induced biliary tree hypertension was studied in 7 patients with a T-tube common bile duct drainage. During saline intravenous administration, increasing biliary tree pressure resulted in pain in 5 patients, with the threshold for pain being 40 cmH2O. During CRL intravenous infusion, significantly higher perfusion pressures were required to achieve a given common bile duct pressure and the pressure threshold for pain was not reached. Consequently, pain was prevented in all patients. These data suggest that CRL relieves biliary colic pain by reducing biliary tract pressure.

Management and long-term results in patients with two-thirds gastrectomy and stomal ulcer☆

In 67 patients with two-thirds gastrectomy and endoscopically proven stomal ulcer, serum gastrin levels were measured under basal conditions and after intravenous infusion of bombesin (15 ng/kg/min), calcium (4 mg/kg/hour) and secretion (2 units/kg). All patients underwent medical or surgical therapy. The long-term results were evaluated according to the Visick grading system (average follow-up, 3.1 years).

Manometric measurement of human sphincter of Oddi length.

Length of biliary (CBD) and/or pancreatic (PD) sphincter of Oddi (SO) was measured during perendoscopic or intraoperative manometry in 21 control subjects and in 46 patients with biliary disease. When the high resting pressure (HPZ) and the phasic wave zone (PAZ) were considered, SO length was, in the control group, 9.5 +/- 0.5 mm (M +/- SE) and 9.4 +/- 0.6 mm at the level of the CBD-SO, and 7.7 +/- 0.6 mm and 6.9 +/- 0.5 mm at the level of the PD-SO. The physiological sphincter length appeared substantially shorter than the anatomical one, as reported in the literature. No significant differences were found between controls and patients with CBD stones. Endoscopic sphincterotomy without manometry reduced mean sphincter length length of the sphincterotomy was tailored to the manometric findings. Surgical partial sphincterotomy reduced sphincter length by only 46.7 +/- 10.3%.

Prostanoids in Jejunal Biopsy Specimens of Celiac Children with Active Disease and on Challenge Diet: Radioimmunologic Evaluation

Prostanoid generation (prostaglandin E2 and thromboxane B2) in jejunal biopsy specimens from celiac patients was evaluated, comparing celiac patients with celiac patients on challenge diet and controls. Generation of prostaglandin E2 in jejunal specimens from 14 children with active celiac disease was significantly higher (341.8 +/- 82.3 ng/g; mean +/- SEM) than that from 7 celiac patients on gluten challenge diet (69.4 +/- 13.2 ng/g) or 8 normal children (92 +/- 23 ng/g) (p less than 0.05). In contrast, thromboxane B2 generation in jejunal specimens from all three groups did not show any statistically significant variation. Our results indicate that prostaglandin E2 generation is not merely related to the activity of clinical symptoms, since patients receiving gluten challenge had prostaglandin E2 levels that did not differ from those of controls.